Template:Stroke Syndromes: Difference between revisions
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====Anterior Cerebral Artery (ACA)==== | ====Anterior Cerebral Artery (ACA)==== | ||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face) | *Contralateral [[numbness|sensory]] and [[weakness|motor]] symptoms in the lower extremity (sparing hands/face) | ||
*Urinary incontinence | *[[urinary incontinence|Urinary]] and bowel incontinence | ||
*Left sided lesion: akinetic mutism, transcortical motor aphasia | *Left sided lesion: akinetic mutism, transcortical motor aphasia | ||
*Right sided lesion: Confusion, motor hemineglect | *Right sided lesion: [[Confusion]], motor hemineglect | ||
*Presence of primitive grasp and suck reflexes | |||
*May manifest gait apraxia | |||
====Middle Cerebral Artery (MCA)==== | ====Middle Cerebral Artery (MCA)==== | ||
[[File:DOAeXAmWsAAAp5g.jpg|thumb|Patient with [[stroke]] (forehead sparing).]] | |||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Hemiparesis, facial plegia, sensory loss contralateral to affected cortex | *[[weakness|Hemiparesis]], [[facial paralysis|facial plegia]], [[numbness|sensory loss]] contralateral to affected cortex | ||
*Motor deficits found more commonly in face and upper extremity than lower extremity | *[[weakness|Motor deficits]] found more commonly in face and upper extremity than lower extremity | ||
*Dominant hemisphere involved: aphasia | *Dominant hemisphere involved: aphasia | ||
*Nondominant hemisphere involved: inattention | **''Wernicke's aphasia'' (receptive aphasia) -> patient unable to process sensory input and does not understand verbal communication | ||
* | **''Broca's aphasia'' (expressive aphasia) -> patient unable to communicate verbally, even though understanding may be intact | ||
*Nondominant hemisphere involved: dysarthria (motor deficit of the mouth and speech muscles; understanding intact) w/o aphasia, inattention and neglect side opposite to infarct | |||
*Contralateral homonymous hemianopsia | |||
*Gaze preference toward side of infarct | |||
*Agnosia (inability to recognize previously known subjects) | |||
===Posterior circulation=== | ===Posterior circulation=== | ||
*Blood supply via the | *Blood supply via the vertebral artery | ||
*Branches include, AICA, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]] | *Branches include, AICA, [[Stroke_(Main)#Basilar_artery|Basilar artery]], [[Stroke_(Main)#Posterior_Cerebral_Artery_.28PCA.29|PCA]] and [[Stroke_(Main)#Posteroinferior_Cerebellar_Artery_.28PICA.29|PICA]] | ||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness) | *Crossed neuro deficits (i.e., ipsilateral [[cranial nerve palsies|CN deficits]] w/ contralateral motor [[weakness]]) | ||
*Multiple, simultaneous complaints are the rule | *Multiple, simultaneous complaints are the rule (including [[syncope|loss of consciousness]], [[nausea/vomiting]], alexia, visual agnosia) | ||
*5 Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia | *5 Ds: Dizziness ([[Vertigo]]), [[Dysarthria]], [[ataxia|Dystaxia]], [[Diplopia]], [[Dysphagia]] | ||
*Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks) | *Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks) | ||
*Approximately 25% associated with aortic dissection | |||
====Basilar artery==== | ====Basilar artery==== | ||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Quadriplegia, coma, locked-in syndrome | *[[weakness|Quadriplegia]], [[coma]], locked-in syndrome | ||
*"Crossed signs" in which a patient has unilateral cranial nerve deficits but contralateral hemiparesis and hemisensory loss suggest brainstem infarction | |||
**Millard-Gubler syndrome (ventral pontine syndrome) -- ipsilateral [[abducens nerve palsy|CN VI]] and [[facial paralysis|VII palsy]] with contralateral hemiplegia of extremities | |||
*Sparing of vertical eye movements (CN III exits brainstem just above lesion) | *Sparing of vertical eye movements (CN III exits brainstem just above lesion) | ||
*One and a half syndrome | **Thus, may also have miosis b/l | ||
**"Half" - INO (internuclear | *One and a half syndrome (seen in a variety of brainstem infarctions) | ||
**"Half" - INO ([[internuclear ophthalmoplegia]]) in one direction | |||
**"One" - inability for conjugate gaze in other direction | **"One" - inability for conjugate gaze in other direction | ||
**Convergence and vertical EOM intact | **Convergence and vertical EOM intact | ||
*Medial inferior pontine syndrome (paramedian basilar artery branch) | *Medial inferior pontine syndrome (paramedian basilar artery branch) | ||
**Ipsilateral conjugate gaze towards lesion (PPRF), nystagmus (CN VIII), ataxia, diplopia on lateral gaze (CN VI) | **Ipsilateral conjugate gaze towards lesion (PPRF), [[nystagmus]] (CN VIII), [[ataxia]], [[diplopia]] on lateral gaze (CN VI) | ||
**Contralateral face/arm/leg paralysis and decreased proprioception | **Contralateral face/arm/leg [[weakness|paralysis]] and decreased proprioception | ||
*Medial midpontine syndrome (paramedian midbasilar artery branch) | *Medial midpontine syndrome (paramedian midbasilar artery branch) | ||
**Ipsilateral ataxia | **Ipsilateral [[ataxia]] | ||
**Contralateral face/arm/leg paralysis and decreased proprioception | **Contralateral face/arm/leg [[weakness|paralysis]] and decreased proprioception | ||
*Medial superior pontine syndrome (paramedian upper basilar artery branches) | *Medial superior pontine syndrome (paramedian upper basilar artery branches) | ||
**Ipsilateral ataxia, INO, myoclonus of pharynx/vocal cords/face | **Ipsilateral [[ataxia]], [[internuclear ophthalmoplegia|INO]], myoclonus of pharynx/vocal cords/face | ||
**Contralateral face/arm/leg paralysis and decreased proprioception | **Contralateral face/arm/leg [[weakness|paralysis]] and decreased proprioception | ||
====Superior Cerebellar Artery (SCA)==== | ====Superior Cerebellar Artery (SCA)==== | ||
*~2% of all cerebral infarctions<ref>Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.</ref> | *~2% of all cerebral infarctions<ref>Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.</ref> | ||
* | *May present with nonspecific symptoms - [[nausea/vomiting]], [[dizziness]], [[ataxia]], [[nystagmus]] (more commonly horizontal)<ref>Lee H, Kim HA. Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry. 2013 Apr;84(4):446-51.</ref> | ||
*Lateral superior pontine syndrome | |||
**Ipsilateral [[ataxia]], [[nausea/vomiting]], [[nystagmus]], [[Horner syndrome]], conjugate gaze paresis | |||
**Contralateral loss of pain/temperature in face/extremities/trunk, and loss of proprioception/vibration in LE > UE | |||
====Posterior Cerebral Artery (PCA)==== | ====Posterior Cerebral Artery (PCA)==== | ||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Common after CPR, as occipital cortex is a watershed area | |||
*Unilateral headache (most common presenting complaint) | *Unilateral headache (most common presenting complaint) | ||
*Visual field defects (contralateral homonymous hemianopsia, unilateral blindness) | *Visual field defects (contralateral homonymous hemianopsia, unilateral blindness) | ||
*Visual agnosia - can't recognize objects | |||
*Possible macular sparing if MCA unaffected | *Possible macular sparing if MCA unaffected | ||
*Motor function is typically minimally affected | *Motor function is typically minimally affected | ||
*Lateral midbrain syndrome (penetrating arteries from PCA) | *Lateral midbrain syndrome (penetrating arteries from PCA) | ||
**Ipsilateral CN III - eye down and out, pupil dilated | **Ipsilateral [[third nerve palsy|CN III]] - eye down and out, pupil dilated | ||
**Contralateral | **Contralateral hemi[[ataxia]], [[tremor]], hyperkinesis (red nucleus) | ||
*Medial midbrain syndrome (upper basilar and proximal PCA) | *Medial midbrain syndrome (upper basilar and proximal PCA) | ||
**Ipsilateral CN III - eye down and out, pupil dilated | **Ipsilateral [[third nerve palsy|CN III]] - eye down and out, pupil dilated | ||
**Contralateral paralysis of face, arm, leg (corticospinal) | **Contralateral [[weakness|paralysis]] of face, arm, leg (corticospinal) | ||
====Anterior Inferior Cerebellar Artery (AICA)==== | ====Anterior Inferior Cerebellar Artery (AICA)==== | ||
*Lateral inferior pontine syndrome | *Lateral inferior pontine syndrome | ||
*Ipsilateral facial paralysis, loss of corneal reflex (CN VII) | *Ipsilateral [[facial paralysis]], loss of corneal reflex (CN VII) | ||
*Ipsilateral loss of pain/ | *Ipsilateral loss of pain/temperature (CN V) | ||
*Nystagmus, | *[[Nystagmus]], [[nausea/vomiting]], [[vertigo]], ipsilateral [[hearing loss]] (CN VIII) | ||
*Ipsilateral limb and gait ataxia | *Ipsilateral limb and gait [[ataxia]] | ||
*Ipsilateral Horner syndrome | *Ipsilateral [[Horner syndrome]] | ||
*Contralateral loss of pain/ | *Contralateral loss of pain/temperature in trunk and extremities (lateral spinothalamic) | ||
====Posterior Inferior Cerebellar Artery (PICA)==== | ====Posterior Inferior Cerebellar Artery (PICA)==== | ||
'''Signs and Symptoms:''' | '''Signs and Symptoms:''' | ||
*Lateral medullary/Wallenberg syndrome | *Lateral medullary/Wallenberg syndrome | ||
*Ipsilateral cerebellar signs, ipsilateral loss of pain/temperature of face, ipsilateral [[Horner syndrome]], ipsilateral [[dysphagia]] and [[dysphonia|hoarseness]], [[dysarthria]], [[vertigo]]/[[nystagmus]] | |||
*Contralateral loss of pain/temp over body | |||
*Also caused by vertebral artery occlusion (most cases) | *Also caused by vertebral artery occlusion (most cases) | ||
====Internal Capsule and Lacunar Infarcts==== | ====Internal Capsule and Lacunar Infarcts==== | ||
*May present with either lacunar c/l pure motor or c/l pure sensory | *May present with either lacunar c/l pure motor or c/l pure sensory (of face and body)<ref>Rezaee A and Jones J et al. Lacunar stroke syndrome. Radiopaedia. http://radiopaedia.org/articles/lacunar-stroke-syndrome.</ref> | ||
*C/l motor plus sensory if large enough | **Pure c/l motor - posterior limb of internal capsule infarct | ||
**Pure c/l sensory - thalamic infarct (Dejerine and Roussy syndrome) | |||
*C/l motor plus sensory if large enough | |||
*Clinically to cortical large ACA + MCA stroke - the following signs suggest cortical rather than internal capsule<ref>Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html</ref>: | *Clinically to cortical large ACA + MCA stroke - the following signs suggest cortical rather than internal capsule<ref>Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html</ref>: | ||
**Gaze preference | **Gaze preference | ||
| Line 86: | Line 106: | ||
**Aphasia (dominant lesion, MCA) | **Aphasia (dominant lesion, MCA) | ||
**Spatial neglect (non-dominant lesion) | **Spatial neglect (non-dominant lesion) | ||
*Others | |||
**Ipsilateral ataxic [[weakness|hemiparesis]], with legs worse than arms - posterior limb of internal capsule infarct | |||
**[[Dysarthria]]/Clumsy Hand Syndrome - basilar pons or anterior limb of internal capsule infarct | |||
===Anterior Spinal Artery (ASA)=== | ===Anterior Spinal Artery (ASA)=== | ||
====Superior ASA==== | ====Superior ASA==== | ||
*Medial medullary syndrome - displays alternating pattern of sidedness of symptoms below | *Medial medullary syndrome - displays alternating pattern of sidedness of symptoms below | ||
*Contralateral arm/leg weakness and proprioception/vibration | *Contralateral arm/leg [[weakness]] and proprioception/vibration | ||
*Tongue deviation towards lesion | *Tongue deviation towards lesion | ||
| Line 96: | Line 119: | ||
*ASA syndrome | *ASA syndrome | ||
*Watershed area of hypoperfusion in T4-T8 | *Watershed area of hypoperfusion in T4-T8 | ||
* | *Bilateral [[numbness|pain/temp]] loss in trunk and extremities (spinothalamic) | ||
* | *Bilateral [[weakness]] in trunk and extremities (corticospinal) | ||
*Preservation of dorsal columns | *Preservation of dorsal columns | ||
Latest revision as of 23:11, 9 July 2022
Anterior Circulation
Internal Carotid Artery
- Tonic gaze deviation towards lesion
- Global aphasia, dysgraphia, dyslexia, dyscalculia, disorientation (dominant lesion)
- Spatial or visual neglect (non-dominant lesion)
Anterior Cerebral Artery (ACA)
Signs and Symptoms:
- Contralateral sensory and motor symptoms in the lower extremity (sparing hands/face)
- Urinary and bowel incontinence
- Left sided lesion: akinetic mutism, transcortical motor aphasia
- Right sided lesion: Confusion, motor hemineglect
- Presence of primitive grasp and suck reflexes
- May manifest gait apraxia
Middle Cerebral Artery (MCA)
Patient with stroke (forehead sparing).
Signs and Symptoms:
- Hemiparesis, facial plegia, sensory loss contralateral to affected cortex
- Motor deficits found more commonly in face and upper extremity than lower extremity
- Dominant hemisphere involved: aphasia
- Wernicke's aphasia (receptive aphasia) -> patient unable to process sensory input and does not understand verbal communication
- Broca's aphasia (expressive aphasia) -> patient unable to communicate verbally, even though understanding may be intact
- Nondominant hemisphere involved: dysarthria (motor deficit of the mouth and speech muscles; understanding intact) w/o aphasia, inattention and neglect side opposite to infarct
- Contralateral homonymous hemianopsia
- Gaze preference toward side of infarct
- Agnosia (inability to recognize previously known subjects)
Posterior circulation
- Blood supply via the vertebral artery
- Branches include, AICA, Basilar artery, PCA and PICA
Signs and Symptoms:
- Crossed neuro deficits (i.e., ipsilateral CN deficits w/ contralateral motor weakness)
- Multiple, simultaneous complaints are the rule (including loss of consciousness, nausea/vomiting, alexia, visual agnosia)
- 5 Ds: Dizziness (Vertigo), Dysarthria, Dystaxia, Diplopia, Dysphagia
- Isolated events are not attributable to vertebral occlusive disease (e.g. isolated lightheadedness, vertigo, transient ALOC, drop attacks)
- Approximately 25% associated with aortic dissection
Basilar artery
Signs and Symptoms:
- Quadriplegia, coma, locked-in syndrome
- "Crossed signs" in which a patient has unilateral cranial nerve deficits but contralateral hemiparesis and hemisensory loss suggest brainstem infarction
- Sparing of vertical eye movements (CN III exits brainstem just above lesion)
- Thus, may also have miosis b/l
- One and a half syndrome (seen in a variety of brainstem infarctions)
- "Half" - INO (internuclear ophthalmoplegia) in one direction
- "One" - inability for conjugate gaze in other direction
- Convergence and vertical EOM intact
- Medial inferior pontine syndrome (paramedian basilar artery branch)
- Medial midpontine syndrome (paramedian midbasilar artery branch)
- Medial superior pontine syndrome (paramedian upper basilar artery branches)
Superior Cerebellar Artery (SCA)
- ~2% of all cerebral infarctions[1]
- May present with nonspecific symptoms - nausea/vomiting, dizziness, ataxia, nystagmus (more commonly horizontal)[2]
- Lateral superior pontine syndrome
- Ipsilateral ataxia, nausea/vomiting, nystagmus, Horner syndrome, conjugate gaze paresis
- Contralateral loss of pain/temperature in face/extremities/trunk, and loss of proprioception/vibration in LE > UE
Posterior Cerebral Artery (PCA)
Signs and Symptoms:
- Common after CPR, as occipital cortex is a watershed area
- Unilateral headache (most common presenting complaint)
- Visual field defects (contralateral homonymous hemianopsia, unilateral blindness)
- Visual agnosia - can't recognize objects
- Possible macular sparing if MCA unaffected
- Motor function is typically minimally affected
- Lateral midbrain syndrome (penetrating arteries from PCA)
- Medial midbrain syndrome (upper basilar and proximal PCA)
Anterior Inferior Cerebellar Artery (AICA)
- Lateral inferior pontine syndrome
- Ipsilateral facial paralysis, loss of corneal reflex (CN VII)
- Ipsilateral loss of pain/temperature (CN V)
- Nystagmus, nausea/vomiting, vertigo, ipsilateral hearing loss (CN VIII)
- Ipsilateral limb and gait ataxia
- Ipsilateral Horner syndrome
- Contralateral loss of pain/temperature in trunk and extremities (lateral spinothalamic)
Posterior Inferior Cerebellar Artery (PICA)
Signs and Symptoms:
- Lateral medullary/Wallenberg syndrome
- Ipsilateral cerebellar signs, ipsilateral loss of pain/temperature of face, ipsilateral Horner syndrome, ipsilateral dysphagia and hoarseness, dysarthria, vertigo/nystagmus
- Contralateral loss of pain/temp over body
- Also caused by vertebral artery occlusion (most cases)
Internal Capsule and Lacunar Infarcts
- May present with either lacunar c/l pure motor or c/l pure sensory (of face and body)[3]
- Pure c/l motor - posterior limb of internal capsule infarct
- Pure c/l sensory - thalamic infarct (Dejerine and Roussy syndrome)
- C/l motor plus sensory if large enough
- Clinically to cortical large ACA + MCA stroke - the following signs suggest cortical rather than internal capsule[4]:
- Gaze preference
- Visual field defects
- Aphasia (dominant lesion, MCA)
- Spatial neglect (non-dominant lesion)
- Others
- Ipsilateral ataxic hemiparesis, with legs worse than arms - posterior limb of internal capsule infarct
- Dysarthria/Clumsy Hand Syndrome - basilar pons or anterior limb of internal capsule infarct
Anterior Spinal Artery (ASA)
Superior ASA
- Medial medullary syndrome - displays alternating pattern of sidedness of symptoms below
- Contralateral arm/leg weakness and proprioception/vibration
- Tongue deviation towards lesion
Inferior ASA
- ASA syndrome
- Watershed area of hypoperfusion in T4-T8
- Bilateral pain/temp loss in trunk and extremities (spinothalamic)
- Bilateral weakness in trunk and extremities (corticospinal)
- Preservation of dorsal columns
- ↑ Macdonell RA, Kalnins RM, Donnan GA. Cerebellar infarction: natural history, prognosis, and pathology. Stroke. 18 (5): 849-55.
- ↑ Lee H, Kim HA. Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry. 2013 Apr;84(4):446-51.
- ↑ Rezaee A and Jones J et al. Lacunar stroke syndrome. Radiopaedia. http://radiopaedia.org/articles/lacunar-stroke-syndrome.
- ↑ Internal Capsule Stroke. Stanford Medicine Guide. http://stanfordmedicine25.stanford.edu/the25/ics.html